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Medical errors have been identified as the fourth most common cause of patient deaths in
the United States. To help reduce the numbers of errors related to incorrect use of
terminology, the Joint Commission on Accreditation of Healthcare Organizations recently
issued a list of abbreviations, acronyms and symbols that should no longer be used. The
action supports one of JCAHO's national patient safety goals: to improve the effectiveness
of communications among caregivers.
Between 44,000 and 96,000 deaths each year may be attributed to medical errors,
spawning efforts throughout the healthcare system to systematically address the issues
and better protect patient safety. JCAHO's national patient safety goals are one example.
This communication shares the information with you as dietetics professionals to take
action to help reduce medical errors.
National Patient Safety Goals
JCAHO's effort to further protect patient safety and address this health care issue is
embodied in the approval and implementation of seven National Patient Safety Goals
(NPSGs). These goals are not accreditation standards -- they are prescriptive accreditation
requirements. In summary, they are:
1.
2.
3.
4.
5.
6.
7.
The National Patient Safety Goals along with their recommendations are published on the
JCAHO Web site to maintain the highest level of accessibility to health care organizations,
ensuring compliance and overall patient safety. The complete recommendations also can
be found on the JCAHO Web site at www.jcaho.org/accredited%2Borganizations/patient
%2Bsafety/04%2Bnpsg/04_npsg.htm.
Responsibility of Dietetics Professionals
All dietetics professionals, especially working in areas of clinical practice or providing
patient food service, need to be aware of this JCAHO initiative. As leaders in health care, I
encourage you to be proactive: Contact your risk managers, patient safety officer and
information management and quality departments to review the information that is
depicted in the tables below, and identify how you can help reduce medical errors.
These goals are not accreditation standards, they are prescriptive accreditation
requirements.
For dietetics professionals working in JCAHO-accredited systems, meeting the national
patient safety goal will be required. But even if you do not work in a JCAHO accredited
facility, you have a role to play in avoiding terms and abbreviations that could compromise
patient safety. For example, if you develop materials for dietetics professionals and
students, you can do your part by proactively eliminating these abbreviations in materials
you produce.
Medication orders are subject to the initiative, but so is all clinical documentation,
including orders, progress notes, consultation reports and operative reports, as well as,
educational materials and protocols/pathways.
In January 2004, as JCAHO conducts its facility surveys, it will check to see that any terms
on the "list of dangerous abbreviations are not found in handwritten clinical
documentation." Organizations found not to be in compliance will be required to submit a
plan for continued improvement.
By April 1, 2004, additional terms will be identified and eliminated from use. By the end of
2004, JCAHO expects full compliance in all handwritten, print and electronic media
documents related to these dangerous abbreviations.
A "minimum list" of dangerous abbreviations, acronyms and symbols
Beginning January 1, 2004, the following items must be included on
each accredited organization's "Do not use" list:
Set
Item
Abbreviation
Potential Problem
Preferred Term
1.
1.
U (for unit)
Write "unit"
2.
2.
IU (for international
unit)
Mistaken as IV
(intravenous) or 10
(ten)
3.
3.
4.
4.
5.
6.
Trailing zero
(X.0 mg),
Lack of leading zero
(.X mg)
5.
7.
8.
9.
MS
MSO4
MgSO4
Q.D.,
Mistaken for each
Write "daily" and "every
Q.O.D.
other. The period after
other day"
(Latin abbreviation for the Q can be mistaken
once daily and every for an "I" and the "O"
other day)
can be mistaken for
"I"
Decimal point is
missed
Potential Problem
Preferred Term
g
(for microgram)
Write "mcg"
H.S.
(for half-strength or Latin
abbreviation for bedtime)
T.I.W.
(for three times a week)
S.C. or S.Q.
(for subcutaneous)
Mistaken as SL for
sublingual, or "5 every"
D/C
(for discharge)
Interpreted as discontinue
whatever medications follow
(typically discharge meds).
Write "discharge"
c.c.
(for cubic centimeter)
JCAHO has created a set of Frequently Asked Questions (FAQs) that explain the new
requirements in greater detail. Visit www.jcaho.org/accredited%2Borganizations/patient
%2Bsafety/04%2Bnpsg/04_faqs.htm.
In addition, the Institute for Safe Medication Practices (ISMP) has published a list of
dangerous abbreviations relating to medication use that it recommends should be
explicitly prohibited. It is available on the ISMP Web site: www.ismp.org.
Additional background information on medical errors:
The problem of medical errors has been highlighted over the years, including by Dr. Lucian
Leape and most recently in a report from the U.S. Institute of Medicine. In its 2000 report
"To Err is Human," IOM defined an error as the failure of a planned action to be completed
as intended -- that is, an error of execution; or the use of a wrong plan to achieve an aim
-- that is, an error of planning.
IOM found that latent errors or system failures pose the greatest threat to safety in a
complex system because they lead to operator errors. These failures are built into the
system and present long before an error occurs. They may be difficult for the people
working in the system to identify since they often are hidden in computers or layers of
management and because people become accustomed to working around the problem.
Discovering and fixing latent failures and decreasing their duration are likely to have a
greater effect on building safer systems than efforts to minimize errors at the point at
which they occur.
For additional information of clarification on dietetics professionals' roles and
responsibilities in ensuring patient safety, contact Ellen Pritchett, ADA's Director of Quality
and Outcomes at epritchett@eatright.org.